STATE AGENCY REPORT

ANNUAL SURVEY OF CHILDREN IN STATE AGENCY INSTITUTIONS FOR NEGLECTED OR
DELINQUENT CHILDREN, ADULT CORRECTIONAL INSTITUTIONS, AND
COMMUNITY DAY PROGRAMS FOR NEGLECTED OR DELINQUENT CHILDREN
FOR 2010-2011 FUNDING PURPOSES.

PART I - INSTITUTION AND STATE AGENCY

Name of Institution, community day program, or adult correctional institution: Address: City/State/Zip:

Name of State Agency: Address: City/State/Zip:

PART II - BASIS FOR ELIGIBILITY
1. Is a regular program of instruction provided for the children in the institution or community day school?	Yes No
2. Is the State agency responsible for providing free public education for the children in the institution	Yes No
3. Is the average length of stay in the institution or community day program at least 30 days?	Yes No

IF ANSWER TO ALL THREE QUESTIONS ABOVE IS YES, PROCEED TO PART III.